voice quiz 4

Tracheoesophageal speech

(TEP) •Performed either at the time of the laryngectomy surgery (referred to as a primary TEP) in an uncomplicated laryngectomy case, or at a later time when sufficient healing has occurred (referred to as a secondary TEP). •Involves surgically creating a small puncture through the posteriortracheal wall into the esophagus. A small one-way valve (prosthesis) is inserted into the puncture in order to prevent its spontaneous closure and prevent the aspiration of pharyngoesophageal contents into the trachea

manual circumlaryngeal massage

*Manual laryngeal tension reduction* •Circular motion of -tip of the hyoid -posterior border of thyroid cartilage -medial and lateral suprahyoid muscles •Basic principles -locate site of focal tenderness or tension -progress from superficial to deep pressure (depends on patient tolerance) -patient vocalizes simultaneously -increase complexity of voicing

modes of communication

*following totally laryngectomy* •Factors effecting decision include: age, cognitive status, motor coordination and personal preferences •Communication options: -Artificial/electromechanical -Esophageal speech -Prosthetic: Tracheoesophageal puncture (TEP)

effect of laryngeal reposturing

-Brief manual displacement, sustained pressure and/or downward traction applied to the larynx can reveal valuable information -While the patient vocalizes, repositioning or stabilizing the larynx can interfere with habituated pattern of muscle misuse. -Brief 'moments' of voice improvement can be identified, shaped and reinforced with digital cueing. -Digital cues faded, patient relies on vibrotactile, kinesthetic, and auditory feedback to maintain improved voice, muscle balance and laryngeal positioning.

advantages of circumlaryngeal

-Determine contribution of laryngeal and extralaryngealmuscle dysregulation to the dysphonia. -"Unloading' the larynx provides a distilled version of the dysphonia -Assures proper diagnosis and management •Indications of improvement (single session) -Improved voice quality -Pain reduction/relief -Normalized laryngeal height and mobility -Reduced muscle nodularity

presurgical counseling

*for totally laryngectomy PT* •Typically conducted two weeks prior to the scheduled surgery date •Establish rapport with the patient and their family •Psychosocial issues are addressed -Identifying the patient's needs -Teaching coping skills -Developing and investigating their support system •Description of possible swallowing deficits and alterations in anatomy' •Practice with alternative modes of communication •Baseline measures are taken for speech, voice and swallowing •Motivate patient and caregivers •Explain voice rehabilitation options

TEP voicing

-TEP voicing •Patient breathes from stoma •Occludes stoma •Exhaled lung air moves up trachea •Air diverted through a prosthesis to pharyngoesophagel(PE) segment •Pharyngoesophagel (PE) segment vibrates •Vibration shaped into words via articulators

cancer treatment

-Treatment dependent upon: •Site and extent of lesion •Nodal involvement •Metastatic status •Presence of other medical conditions •Patient choice •Physician/institution preference -Surgery -Radiation -Chemotherapy

etiology of dysphonia

*in vocal performers* •Physical over-compensation of the voice/speech production mechanism as a result of infection and irritation to the larynx •Excessive muscle tension typically localized to the larynx •Engaging in phonotraumatic behaviors such as yelling, screaming, or talking too loud •Improper vocal training •Singing in an unnatural pitch or tense, poor amplification •Poor environmental conditions, and emotional reaction stemming from the stresses of one's daily lifestyle

changing behaviors

*voice therapy involves changing behavior* •Change happens with and without formal intervention •Change is a process, not a straight line •There are skills that clinicians can use that influence the rate and success of change

3 laryngeal reposturing maneuvers

1.Digital compression in posterior direction within region of the hyoid bone •Hyoid 'push-back' technique -Vary height and pressure 2. Impede laryngeal elevation by applying downward traction over the superior border of the thyroid cartilage. •Hyoid 'pull-down' maneuver 3. Medial compression and downward traction with most pressure directed over the posterior aspect of thyroid cartilage (and within the thyroid space) good for non-adductedhyperfunction

total laryngectomy

Respiration •Permanent tracheostoma created -Breathing via "stoma- a hole in the neck" not through nose and mouth -Loss of smell and taste; nose and mouth not connected to trachea -Loss of filtration, heating, and moisturizing effects •Swallowing -No concern for aspiration •Phonation -aphonia

take home points

for the voice clinician •Changing behavior is hard •Readiness for change is measurable •Clinicians can have an impact on a patient's ability to change his or her vocal behavior •The way the clinicians talk to the patient impacts their success •Motivational interviewing gives the clinician skills to talk to patients and encourage change.

reflections

helps the patient hear what they said •From our discussion, it appears that you are angry that you have to continue teaching despite your voice difficulties. •If I understand you correctly, you enjoy going to the bars with friends and don't want to give that up for your vocal health. •It seems that your life is very hurried right now with the kids, work, and the addition of finding time and sitters to come to voice therapy.

dysphonia

It is widely agreed that dysphonia in professional voice users can have a devastating effect on vocal performance

convo strategies

to increase adherence! •Open-ended questions •Affirmation •Reflections •Summarize/clarify

voice therapy works

BUT... •You have to come to therapy to make it work. •Patients must play an active role in their own improvement. •Few patients know what to expect in voice therapy, and few physicians can explain it. •The therapeutic relationship is important for success.

open ended questions

Encourage dialogue •What concerns you about your voice? •If you wanted to.............. (e.g., quitting smoking), how would you do it? •What would you like to accomplish in this session/evaluation? •What do you predict are some of the potential problems with continuing to ...................... (e.g., yell at your kids at home)?

affirmation

tells the patient you are listening •I appreciate that you took such a big step towards changing your voice this week. •Thanks for coming in prepared for therapy. •You have really done an amazing job of preserving your voice despite the barriers you encounter.

high risk performers

•"High Risk" performer is a term used to describe performers who work in major theme parks -Five to seven shows per day in a five-day workweek •Variables they encounter include physical interference with costumes, poor stage acoustics and improper amplification, ranging from inferior microphone placement to no amplification at all •The types of voice disorders theme park performers present with include vocal fold nodules, vocal fold polyps, edema, and hemorrhagic conditions

recommendation statistics

•50% of people don't follow long-term medication recommendations •80% of people don't follow advice to change health behaviors •38% of people don't follow a physician's recommendation for voice therapy •47% of clients who attend the first therapy session do not return to complete therapy •35% of clients drop out of voice therapy

cancer

•A class of diseases characterized as the uncontrolled growth of malignant cells •Primary risk factor for laryngeal cancer: -Smoking and alcohol consumption -Poor nutrition -Race (African American, Caucasian> Asians and Latinos) -Gender (Men 4 times more than women) -Human papilloma virus (HPV) -Chronic irritation (GERD, laryngitis) Weak immunesystem

motivational interviewing

•A patient-centered directive therapy approach that -Is a collaborative conversation about behavior utilized to enhance changes in behavior -Is most successful at the early stages of therapy -Assists people in readiness for change -Encourages active participation by the patient -Is designed to assist the patient through ambivalence toward therapy

patient safety

•After laryngectomy the patient is classified as a neck breather. •Some individuals may choose to wear a special "medic alert" bracelet or necklace. These items identify the person as a total neck breather •Clinicians should also advocate that their patients contact their local emergency medical services (EMS) following surgery to alert the local responders of their address and register that they are a neck breather •Patients and their families should be educated about purchasing an Ambu bag (i.e., a squeezable bag with a face mask) at a local medical supply store •the Ambu bag can be utilized with a pediatric mask that can be placed on the *stoma for CPR administration.*

cool downs

•After rigorous singing activity "cooling down" the voice may be helpful •Singers may elect to vocalize on a gentle and softly engaged hum gliding down in a relaxed manner •The purpose of any type of relaxation or "cool down" exercise is to make coordination easier •Another goal during the "cool down" is to allow the jaw to remain relaxed, loose, and open -Clinicians can instruct the singer to breathe inand allow the sound to feel like the beginningof a yawn

semi-occluded vocal tract exercises

•Based on the premise that vocal injury can be minimized if vibration dose and collision stress in the vocal folds are reduced. •One primary application is for clients who suffer from the effects of long hours of daily speaking, such as teachers in classrooms. •The intent is not simply to train clients to talk softer, as in so-called "confidential voice" or by using amplification , but to produce normal vocal intensity with less mechanical trauma to tissues.

breath coordination

•Breathing exercises -Help coordinate respiratory effort and laryngeal configuration for singing and speaking -Used to eliminate hyperfunctional or hypofunctional behaviors -Improve sound duration, singing dynamics (soft voice vs. loud voice) •Singers -Extend the length of sound production more than typical voice users -Use more variations in frequency and intensity when they sing with varying emotions Need to develop various levels of subglottal pressure

esophageal speech

•Can be produced when the individual transports a small amount of air from the oral and pharyngeal cavity into the esophagus -The air is redirected back past the pharyngoesophagel (PE)segment to force vibration of the tissue -Rapid repetition of the air transport can ultimately produce intelligible esophageal speech -The patient then forms this sound into words with the tongue, lips, teeth, and palate •A: Tongue press to inject air into esophagus •B: Air enters esophagus •C: Air release from esophagus to produce voice •D: Voice shaped into speech

cancer surgical options

•SLP's do not make surgical decisions, however accurate understanding of the extent of the resection and reconstruction will help to insure accurate and informative counseling for patients •Laryngectomy Types: -Total Laryngectomy -Partial Laryngectomies

staging head and neck cancer

•Staging system, developed by the American Joint Committee on Cancer (AJCC): -Tumor (T): primary tumor size, location, and involvement -Nodal disease (N): lymphatic spread; regional metastasis -Metastasis (M): distant metastasis beyond head and neck region

circumlaryngeal massage

•Clinican-based factors -Clinician experience and confidence regarding expectations must be communicated directly to the patient -Patient learns 'by doing' -Physical 'perturbation' of the larynx is often necessary to elicit improved voice and to interfere with abnormal laryngeal postures -Pace of therapy should be fast momentum through treatment hierarchy is crucial -Sustained attention to the task by client and clinician is essential •discourage frequent interrruptions/distractions -Patient is an active participant in therapy •needs to 'tune into' any improvement in voice -Clinician needs to know when to confront the patient when effort is not commensurate with task demands •Acceptable and necessary to be demanding of the client -Clinician must enthusiastically reinforce even minor improvements in voice and immediately call client's attention to those 'magic' moments -Successive approximations of more normal voice are desired and typical during MTD therapy -Clinician must possess and demonstrate a facility with a wide array of facilitating techniques to stimulate voice -Clinician must know when to abandon techniques that are not fruitful and when to maintain techniques that seem promising (i.e., not to abandon a technique prematurely) -Clinician must communicate that the client is responsible for the improvement observed •client needs to establish a sense of self-mastery over voice production -May attempt 'negative practice' to demonstrate to the patient that he/she is capable of self-mastery

treatment approach

•Excessive muscle tension Focus on decreasing the excessive glottal and subglottal muscle tension •Reduced by using facilitating approach such as auditory feedback, change of loudness, chant talk, chewing, counselling, focus, changing glottal attack, laryngeal massage, open-mouth, relaxation, and yawn-sigh

slp role

•Help the client to produce and habituate more appropriate vocal behaviors •Identify and understand factors that affect vocal behavior •Tailor treatment plan to: -personal and lifestyle characteristics -voice goals •Help the client to look at the style and pattern of interpersonal interactions •Communicate with other professionals and co-workers, where appropriate. •Provide support and practice opportunities to habituate new vocal patterns.

cancer signs and symptoms

•Hoarseness (without pain) •Changes in vocal quality and intensity •Sore throat •Palpable lump on neck •Globus sensation •Ear pain (otalgia) •Shortness of breath (dyspnea) Noisy breathing (stridor) Persistent cough Throat pain Weight loss Halitosis (unpleasant breath odor) Odynophagia (pain with swallowing) Dysphagia

assessing potential for change

•How confident are you that you will practice your voice exercises? -When you are busy? -When you are tired? •How confident are you that you will use your target voice when -At work? -On the phone? -In social situations? With people who "push your buttons?"

vocal warm ups

•Hypothesized to improve vocal performance and help prevent vocal injury •In general, it is believed that warming up the voice improves the performance of the individual muscles of the lung/thorax unit, larynx, and vocal tract •Helps coordination between the subsystems of voice production (respiration, phonation and resonance). •Most vocal warm-up routines are approximately 20minutes or less in duration •Contain a variety of different exercises (some voiced, some unvoiced) to focus upon respiratory and laryngeal muscles activation and coordination •Regular use of vocal warm-ups is considered good "singing health"

psychosocial voice disorder

•If a person's ability to use the voice is restricted in some way, -listeners react negatively -there may be a disruption in social interaction which affect person's self esteem and sense of competency and control. •Consider the client's role as a unique individual, within family, social and cultural systems. •Act as consultant, facilitator, counselor to shape attitudes relevant to behavioral change •listen, observe, be empathic and signal respect with reflecting statements

factors that impact voice therapy

•In therapy, there are both facilitators and barriers •Internal factors -Cognition -Emotional -Psychological •External factors -Environmental Social

other exercises

•Lip buzzes/tongue trills/bilabial fricatives -Sometimes used as warm-up exercises -Starts with sustained tones at different pitches followed by glides (often used with singers) -Start first with sustained buzz at habitual pitch Focus on sensation of vibration and "open throat," not the quality of the sound (but must be voicing) -Progress to •voiced bilabial/labiodental fricatives •lip or tongue trills •nasal consonants •vowels /u/ and /i/ •Other semi-occlusions of the vocal tract are the nasal consonants (/m/, /n/, or /ŋ/). -The nasal tract becomes the vocal tract, with the nostrils becoming the semi-occlusion. •Similar to voice therapy techniques have been built on the frequent use of nasal consonants, including the vocal function exercises by and the resonant voice training

professional organizations

•NATS - National Association of Teachers for Singers is dedicated to encouraging the highest standards of singing through excellence in teaching and the promotion of vocal education and research •VASTA - Voice and Speech Trainers Association, Inc. Voice Foundation - the world's oldest and leading organization dedicated to voice medicine, science, and education

cancer diagnosis

•Patient history •Head and neck exam •Visualization of the larynx -Indirect laryngoscopy Mirror exam Flexible/rigid endoscopy and stroboscopy •Direct laryngoscopy -Under general anesthesia -Biopsy Radiologic studies CT scan (computed tomography) MRI (Magnetic resonance imaging) MBS (Modified barium swallow study) Chest X-ray

slp role in cancer

•Presurgical counseling, Postsurgical counseling and management to maximize functional outcomes and improve quality of life •Offering modes of communication following total laryngectomy

post surgical counseling

•Readdress psychosocial issues: -Talking about patient and family support systems -Available community resources -Lifestyle changes -Nutritional changes •Encourage participation in support groups •Facilitate socialization •Assist in the emotional recovery •Teach modes of speech

readiness for change

•Readiness is a reflection of -Confidence in the ability to change behavior -Commitment towards changing the behavior •Readiness can be measured! with predicting clinical success scale

straw phonation

•Straw phonation works to unload the vocal tension of a hyperfunctional voice. -A tense voice has a longer closed phase of true vocal folds (TVF) vibration with associated higher impact of the folds. -With the longer closed phase, subglottic air pressure is increased. -This also causes the TVFs and larynx to be pushed superiorly. •By partially occluding the airway above the level of the TVFs (i.e., at the lips), the supraglottic air pressure increases, decreasing transglottal pressure, so that the ratio of sub- to supraglottic pressure is reduced. •As the subglottic pressure is reduced, the TVFs separate, and the open phase and flow rate increases, resulting in decreased vocal fold impact. •Phonate through straws of various diameters and lengths -Highly resistant (small diameter) stirring straws -Less resistant (larger diameter) drinking straws •After the client successfully phonates using the smaller straw, a larger straw can be used to increase airflow to more normal rates for relaxed phonation at an appropriate intensity level. •This should be practiced at appropriate pitch and intensity levels, then with conversational or singing voice with proper diaphragmatic breath support and posture.

vocal load and environmental setting

•The effects of vocal load have a significant impact on vocal function; -Vocal fold vibration, manipulation of vocal loudness, environmental irritants, dehydration •Background sound level -Most frequently use their voices in excessive noise background settings (e.g., hard rock concert performers and classroom teachers) -Excessive noise may compromise respiratory function, pitch changes, voice quality, and overall phonatorystability

teachers

•The professional group experiencing the most vocal problems -Between 15%-32% of teachers reported experiencing a voice disorder in their teaching careers -Prolonged voicing times and talking against noisy backgrounds are frequent causes of voice problems •Teachers with voice disorders -Require a full medical and diagnostic evaluation, appropriate medical management, and individualized voice therapy -A SLP may visit a classroom to see and hear the teacher's voice behavior such as hyperfunctional voice -Use a voice amplifier -Roy and colleagues (2013); Positive voice outcomes on the Voice Handicap Index for teachers with voice problems using a portable voice amplifier in the classroom

professional voice

•The professional voice user -Occupational competence is shaped by their voices -Singer, actor, teacher, salesperson, minister, telemarketer, politician, broadcaster, etc. •The professional voice users exert unusual demands on respiration, phonation, and resonance. •The care of the professional voice creates challenges and requires special skills from physicians and voice pathologists/therapists •Professional voice users span a broad range of vocal sophistication and their livelihood relies heavily on a producing exceptional vocal quality and sustaining vocal endurance

medical social and singing history

•The singer often requires additional detail to be gathered during the interview process •Singer's Voice Handicap Index (SVHI) is a recommended tool to help the clinician understand the performer's perception of their singing difficulties •The history of inhalant or food allergies, or laryngopharyngeal reflux (LPR) •Information should be gathered about use of amplification (i.e. whether or not it exists or is used) •the sound levels required of the song production •types of costumes worn, stage •back stage setting •Information should be gathered about singing training, singing style(s), performance schedule, and warm-up/cool-down practice should be discussed with the performer

singing assessment

•The voice pathologist should closely observe the extent of vocal range that can be produced with ease versus those notes that are produced with increased effort •The voice pathologist should try to document the effort that is produced during the song production, evaluating perceived strain, anatomical posture, maladaptive postures of the neck, jaw, or spine, poor phrasing lengthy phrase duration, changes in breath management, etc. •Compare the client's previous auditory recordings with the new recording made at the time of evaluation (auditory feedback) -Identify what needs to be accomplished in future voice therapy situations

assessment of vocal performers

•Thorough medical history, behavioral/social history, questionnaires regarding their use of voice and their perceived voice-related quality of life (e.g., Singing Voice Handicap Index, S-VHI) •Video stroboscopic assessment of the larynx using both the rigid and flexible scope •Objective voice measures •Auditory/visual perceptual assessment of the speaking and singing voice

TEP sound generation

•To produce sound the patient inhales then exhales as the tracheostomais occluded -Occlusion can be made by: •Finger placed over the tracheostoma •Valve which will allow hands free speech

tumor staging

•Tumor location classified as -Glottic (the area that includes the vocal folds) -Supraglottic (the area above the vocal folds) -Subglottic (the area below the vocal folds) •Staging of laryngeal cancer -Provides specific prognostic and severity rating -Stage 0 - Stage IV (least to most severe) -Nodal involvement dramatically affects staging

electromechanical speech

•Useful in the early postoperative phase when the patient cannot use other voice rehabilitation techniques -Voice pathologist •Selects the most appropriate device •Teaches basic use/care •Assess for neck placement post-healing •Trains the patient to use the device in all communicative settings

vocal performer

•Vocal performer is a label used to classify a large number of individuals who earn a living using their voices •Many vocal performers have attributes that make them exciting on-stage: high levels of habitual energy, ability to communicate a large range of strong emotions, high degree of sensitivity, awareness, and concentration

speaking voice assessment

•Voice difficulty: not caused by singing voice production but caused by speaking voice production -The voice pathologist should evaluate •appropriate speaking pitch(es) •pitch used at the end of a phrase •phrase duration •rate of speech •breath management •breath holding posturing •muscle tension •resonance/resonant focus •persistence of glottal fry featuresof vocalloudness

summarize/ clarify

•You want to change the quality of your voice, but you are having a hard time practicing outside the therapy session. •You understand that .........(e.g., smoking) is contributing to your voice problem but you don't want to stop ......... right now. •The granuloma on your vocal cords is most likely caused by reflux, but you really don't believe in reflux and don't want to take your medication.